Question

Anwser in your own words

Describe in your own words, what should be included in health record documentation best practices. Provide at least one example of how HIM's ensure these best practices are met.

Answer 1

IMPORTANCE OF HEALTH INFORMATION MANAGEMENT

HIM is vital for every healthcare organization and associated business. Not only are there legal requirements that must be adhered by to receive certain incentives and avoid penalties, but organizations have an ethical responsibility to protect PHI in their possession.

Breaches impact patient trust in a healthcare provider and may prohibit a patient from sharing vital information for fear of exposure. Hackers can also steal patient payment information causing residual harm such as identity theft and stolen money. Both of those factors can impact a patient’s willingness to seek care at certain providers.

A focus on HIM also allows an organization many positive benefits such as the potential for increased efficiency and optimization of healthcare information system access and other key aspects involved with revenue cycle management. A coordinated effort to standardize and efficiently operate tasks involving PHI will take a manager dedicated to the task, especially in larger organizations.

Essential Elements for Good Documentation

Documentation should accurately reflect the needs of the patient, the
treatments and interventions provided, and the patient’s outcomes. Anyone
reading the record should clearly be able to determine:

1. What care/service was provided
2. Who received the care
3. Who provided the care or service
4. When the care or service was provided
5. Why the care or service was provided
6. The patient’s response and outcomes to the care or service provided

What care or service was provided
Healthcare providers should be clear and concise in their description of the care provided. Each
patient contact, including the mode of contact if it is not in-person (e.g. by telephone, email,
videoconference telemedicine), should be documented according to organizational policy and professional practice standards.

• Avoid ambiguity, judgmental adjectives, and verbosity – words such as “unintentionally,”
“inadvertently,” and “unexpectedly” should be avoided as they reflect a judgment that
something untoward happened.

• Try not to use subjective descriptions like “ate well” or “feels better”. Where applicable, use
the patient’s own words, e.g. “Patient states she is feeling better.”

• Do not leave blank lines between entries or blank spaces on paper records since this leaves
the entry open to being altered.

Who received the care

Healthcare providers should ensure every page of the health record has the requisite patient identifier(s) to mitigate missing documentation when pages are separated from the health record. Patient identification on both sides of a double-sided form reduces the likelihood of the document being mixed up when it is photocopied, scanned, or faxed. In an electronic health record (EHR), ensure entries being made relate to the right patient.

Who provided the care or service

Anyone reading the documentation should be able to clearly identify the healthcare provider who performed the assessment, procedure or activity. Healthcare providers should put a dated signature or initial and professional designation on every entry. The full names and titles of all healthcare providers should be documented on a master signature list. There may be the rare instance when it becomes necessary to record the care provided by others (e.g. during a code
blue), but in general such practices are discouraged

To help minimize the risks inherent with verbal orders, healthcare teams should adopt a structured communication approach so the order is read back and/or spelled out and a second person listens to the verbal orders where possible.
When receiving a verbal order, include:

• the name and signature of the transcriber, and the name of the healthcare provider
who gave the telephone order;

• the verbal order details, including when the verbal order was initiated, and by whom
Verbal orders should be signed by the originator of the order upon his/her return
to the healthcare organization. We recommend that healthcare organizations have defined policies around who can accept a verbal order (e.g. ward clerk) and under what circumstance. And we also suggest that you consider prohibiting verbal orders for higher risk medications (e.g. chemotherapy).

When the care or service was provided

The date and time of treatments, discussions or other provisions of care, as well as the date and time the healthcare provider records this information should be clearly documented. Timely documentation is especially important in high volume, acuity and turnover areas (e.g. obstetrics, the emergency department and intensive care unit) in order to keep members of the interdisciplinary team informed about changes in a patient’s status.

Memories fade with time – the longer the delay between the event and the recording, the more likely the possibility of incomplete information and errors. Delays in recording can also result in plaintiff’s counsel claiming the care was inappropriate. Most medical-legal claims, with the exception of obstetrical and paediatric claims, remain open for an average of four to seven years. Obstetrical cases can remain open for considerably longer (18+ years). As the healthcare provider, you may be asked to recall – in minute detail – what took place years ago at a very specific date and time.

Why the care or service was provided

The purpose of each encounter should be included in the healthcare provider’s documentation.

Documentation should explain why the healthcare provider did what they did given the clinical circumstances.

The patient’s response and outcomes to the care or service provided

To ensure documentation effectively tells the patient’s story, you should always document
the patient’s response and outcomes to the interventions or care provided. Documenting the
patient’s response and outcomes demonstrates that the care provided was monitored from an
effectiveness and safety perspective.

CLINICAL DOCUMENTATION BEST PRATICES FOR EVERY DOCTOR

Some good work is being done in the US and elsewhere designed to help clinicians improve their documentation, both to meet CMS regulations and prepare for next year’s ICD-10 changeover. Below are three best practices all physicians should consider implementing.

• Ensure that the six Cs are always included in the patient record: cause of the symptoms, chronic conditions that could impact patient care, clinical significance of abnormal test results, check laterality (note right or left side), clarity (can the reader follow your ideas, and current state (is the patient’s problem list and medication list current?).

• Designate someone in your practice to educate themselves on the importance of accurate clinical documentation and how accuracy can impact both patients and the practice. In addition to becoming the go-to person for documentation clarification, this individual can work with the physicians to create measurable goals for documentation improvement.

• Conduct periodic documentation reviews, making sure everyone in the practice understands this is being done to identify knowledge gaps, not to punish individuals.

Because clinical documentation improvement programs can be controversial, the person in charge of the program must be considered a peer by the physicians the program is targeting. “By using peers to provide guidance on clinical documentation, I established a higher level of credibility and respect, and I minimized the physician resistance I sometimes encounter as part of a traditional CDI program,” writes Chicoye. Sound advice for those striving to capture the type of complete clinical data practitioners need to be appropriately reimbursed and prepared for documentation-related questions from patients, auditors, and attorneys